VITAMIN D STATUS : A GLOBAL VITAMIN D STATUS : A GLOBAL VITAMIN D STATUS : A GLOBAL VITAMIN D STATUS : A GLOBAL

PERSPECTIVEPERSPECTIVEPERSPECTIVEPERSPECTIVE

VITAMIN D STATUS : A GLOBAL VITAMIN D STATUS : A GLOBAL VITAMIN D STATUS : A GLOBAL VITAMIN D STATUS : A GLOBAL

PERSPECTIVEPERSPECTIVEPERSPECTIVEPERSPECTIVE

Ambrish Mithal MD, DM

President, Endocrine Society of India

Chairman, Bone Joint Decade, India

What is normal vitamin D level –based on biological impact ?

1. Level below which PTH starts to rise

OR

2. Level at which fractional calcium absorption peaks

OR

3. Level at which bone density is optimal

OR

4. Level at which adverse clinical effects are reduced-fractures, falls, muscle strength.. Or non skeletal effects??

• ?ALL OF THE ABOVE

• Technical issues regarding 25(OH)D assays: mean between lab CV ~20-30%

Optimal Vitamin D for multiple health outcomes

• Desirable

25(OH)D conc.

for optimal

health begins at

75 nmol/L; and

the best conc. is

90-100 nmol/L

Bischoff-Ferrari et al, 2004

Role of Vitamin D in human body-beyond bones!!

• Bone health

• Muscle power

• Immune system

• Cancer

• Skin

• Cardiovascular system

• Diabetes

• Neurological disorders/depression

Optimal 25(OH)D levelsstill controversial…

>30ng/ml

(>75nmol/l)

Vitamin D sufficiency

10-29ng/ml

(25-74nmol/l)

Vitamin D insufficiency

Optimum 25 OHD levelworking definition

• IDEAL > 30 ng/ml (

United States

United States of America

25-41°

United States

• Prevalence of vitamin D deficiency (

• Prevalence of low serum 25(OH)D levels vary by race/ethnicity

• Decline in 25(OH)D levels by 20% in 2000-2004 NHANES survey as compared 1988-1994

• Reasons – increase in BMI, decrease in consumption of vitamin D fortified milk, widespread sunscreen use

Looker AC et al Bone 2002;30(5):771-777

Holick MF et al JCEM 2005;90(6):3215-24

United States

Canada

Canada

• 93% healthy adults- 25(OH)D

Canada

• Prevalence of low 25(OH)D levels is greatest

during winter half of year

• Travel to lower latitudes (below 42°N) is

associated with increase in 25(OH)D levels

• Increasing age associated with lower 25(OH)D

levels

• Average serum 25(OH)D concentrations of

Canadians are similar to those of Europeans

Latin America

Latin America

33°N to 55°S

Vitamin D status in Latin America

50.631.265.8Mexico

96.818.963.6Mexico

67.126.265.6Mexico

50.430.262.6Chile

42.432.667.6Brazil

8717.671.3Argentina

%

Latin America

• Latitude variation

Mean 25(OH)D in elderly population from Argentina-– 20.7ng/ml(northern)

– 14.2ng/ml(southern)

• Seasonal variation-

Mean 25(OH)D in ambulatory women from Buenos Aires-– 25.3ng/ml(summers)

– 21.3ng/ml(winters)

Oliveri B et al Eur J Clin Nutr 2004;58:337-42J

Fradinger EE et al Medicina 1999;59:449-52

Europe

Euronut Seneca Study:

– Southern Europe 8-12 ng/ml (20-30 nmol/l)

– Northern Europe 16-20 ng/ml (40-50 nmol/l)

MORE Study:Decreasing level as we go South!!

Other studies:Low levels in Greece, Spain, Italy as compared to the

Netherlands

Lowest level in immigrants in the Netherlands- Turkish, Moroccan

Europe

• France: SUVIMAX study- age 35-65, men and women: results as expected

– North France- 17.2 ng/ml (43 nmol/l)

– Southwest France- 37.6 ng/ml (94 nmol/l)

Low 25 OH D level predicted poor physical

performance, falls and fractures.

Europe

EuropeLatitude/25OHD paradox

Possible reasons why North has better vitamin D status:

fatty fish intake- upto 400 iu/day

light skin colour

Sun seeking behaviour in the North vs

Sun fleeing in the South

Middle East

Middle East(15-30°N)

Vitamin D status in the Middle East

40-80%Neonates

10-60%Mothers

70%

80%

32%

Adolescents girls- Iran

-Saudi Arabia

-Lebanese

56%Lebanese elderly women

37%Lebanese elderly men

25(OH)D

Middle East

• Mean 25(OH)D is 4 to12ng/ml [university students and elderly, Saudi Arabia

• Highest proportion of hypovitaminosis D is present in women with osteoporosis from Middle East (Lips 2006)

No data from Africa available

South and East Asia

India

• North India – 2 - 12 ng/ml (5 to 30 nmol/l )

• South India- 6 – 20 ng/ml (15 to 50 nmol/l)

All ages deficient

Summer better than winter

South better than North

Rural better than urban

Paramilitary forces better

VITAMIN D STATUS IN OTHER COUNTRIES OF SOUTH EAST

ASIA

VITAMIN D DEFICIENCY: A CONCERN IN PREMENOPAUSAL BANGLADESHI WOMEN

OF TWO SOCIO-ECONOMIC GROUPS IN RURAL AND URBAN REGION

� Latitude 20°43' to 26°36'N and Longitude 88°3' to 92°40'E

� A cross-sectional study

� Two regions of Bangladesh. The Dhaka city area and west region of Nandail (BetagairUnion), Mymensingh.

� Bangladeshi women aged 16-40 y

� Representative subjects of two groups

� LSES (L), n=99

� HSES (H) n=90

M Z Islam, et al. EJCN 2002 ;56 (1) : 51-56

RESULTS

Group L Group H

Prevalence of

hypovitaminosis D

VITAMIN D STATUS OF BREASTFED PAKISTANI INFANTS

� 62 breastfed healthy infants and their nursing mothers belonging to the upper and lower socioeconomic classes

� The mean serum 25(OH)D – 13.8±10.6 ng/ml

� 25(OH)D levels 6 months (p < 0:001).

Acta Paediatrica, 87, 737-740, 1998

SRI LANKAPeak bone mass as measured by phalangealbone mineral density and its association with nutritional status, socioeconomic status and

physical activity

� Total of 582 healthy females aged 30-39 years.

Extract from the PhD thesis by Dr M Rodrigo, Faculty of Medicine, Galle, Sri Lanka

27.5164.18SAP (IU/L)

24.7114.1225(OH)D

(ng/ml)

24.6449.97PTH (pg/ml)

SDMean Parameter

Malay women n=103

Chinese women n=173

Mean 25 (OH) D ng/ml

20-40 ng/mL

10-20 ng/mL

17.76±4.24

27%

71%

27.52±6.28

87%

11%

Suriah A Rahman, et al Asia Pac J Clin Nutr 2004;13 (3):255-260

VITAMIN D STATUS AMONG POSTMENOPAUSAL MALAYSIAN

WOMEN (50-65 years)

VITAMIN D STATUS AND ITS ASSOCIATION WITH PARATHYROID HORMONE CONCENTRATIONS IN

WOMEN OF CHILD-BEARING AGE LIVING IN JAKARTA AND KUALA LUMPUR

� A cross sectional study

� Sample of 504 non-pregnant women 18–40 years

� In two Asian cities, – Jakarta (6°S) and Kuala-Lumpur (2°N)

� Mean 25-hydroxyvitamin D -19.2 ng/ml

� 25 OH Vit D

DISTRIBUTION OF PLASMA 25-OHD CONCENTRATIONS IN GIRLS AGED 12–14 Y IN

WINTER (N = 603) AND SUMMER (N = 254) IN THE BEIJING AREA (LATITUDE 40°N).

PREVALENCE AND IMPACT OF VITAMIN D INSUFFICIENCY IN SOUTHERN CHINESE

ADULTS

� 382 community dwelling Chinese adults

>50 years

� Mean age - 69 ± 9 years.

� Mean 25(OH)D - 28.3 ± 10.8 ng/ml.

� 25(OH)D

Japan

� Overall better than south/south east asia

� Common in inactive elderly

� Positively related to fish consumption

� Active elderly- 95% above 30 ng/ml !

Nakamura K, J Bone Miner Metab, 2006

Oceania

Australia, New Zealand, New Guinea,

Pacific islands 30°N-40°S

Vitamin D status in Australia

• 25(OH)D level

Australia

• Greater hisk in immigrants:

middle eastern origin in Sydney- 4 fold risk;

Vietnamese origin- 3 fold risk

Season appears to be more important determinant than latitude

• Risk factors - Greater disability, restricted sunlight exposure, dark skin color, cultural practices, prolonged breast feeding, younger maternal age, chronic medical conditions

New Zealand

• Mean 25(OH)D - 19ng/ml in women21ng/ml in men

• Mean 25(OH)D of women in South Island of New Zealand was 2.4ng/ml lower than that in North Island.

• Pregnant women – 87% had 25(OH)D

Conclusions

• Vitamin D insufficiency common globally

• 25 (OH) D level of 30 ng/ml rarely seen!

• South Asia and Middle East worst hit despite sun and favourable latitude!!

• Key factors:– Skin pigment/ethnicity,

– outdoor exposure (age, cultural)

– season

– latitude

• Fortification important in some areas

Global status

Europe Paul Lips

Australia John Eisman

Central Asia/ Africa El Hajj Fuleihan

South/South East Asia Ambrish Mithal

North America (USA) Bess Dawson- Hughes

North America (Canada) R. Josse

Latin America Morales Torres

J.P. Bonjour, Peter Burckhardt